"No vision haunts America’s conscience more than the sight of the street people… The irrationality and anguish that grip so many of these individuals leap out during any encounter, whether in Washington or Albuquerque."---Senator Pete Domenici (R-NM)

SUMMARY: People with untreated psychiatric illnesses comprise one-third, or 250,000, of the estimated 744,000 homeless population. The quality of life for these individuals is abysmal. Many are victimized regularly. One study found that 28 percent of homeless people with previous psychiatric hospitalizations obtained some food from garbage cans and 8 percent used garbage cans as a primary food source.

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Between 250,000 individuals with schizophrenia or manic-depressive illness are homeless among the 744,000 homeless population (total homeless population statistic based on data from a 2007 national survey). These 250,000 individuals are equivalent to the population of such cities as Dayton, Ohio; Des Moines, Iowa; Fort Lauderdale, Florida; Grand Rapids, Michigan; Providence, Rhode Island; Richmond, Virginia; or Salt Lake City, Utah.

· A 2007 survey by the National Alliance to End Homelessness reported that there were approximately 744,000 homeless persons in the US. Among these, approximately two- thirds were single persons and one-third were families. One-quarter of the homeless persons were said to be chronically homeless. Numerous studies have reported that approximately one-third of homeless persons have a serious mental illness, mostly schizophrenia or bipolar disorder. The percentage is higher among those who are chronically homeless and among homeless women and is lower among homeless families. If overall one-third of homeless persons are seriously mentally ill, that means that there are approximately 250,000 homeless persons with serious mental illnesses in the US.

At any given time, there are many more people with untreated severe psychiatric illnesses living on America’s streets than are receiving care in hospitals. Approximately 90,000 individuals with schizophrenia or manic-depressive illness are in all hospitals receiving treatment for their disease.

The New York Times reported that in Berkeley, California, "on any given night there are 1,000 to 1,200 people sleeping on the streets. Half of them are deinstitutionalized mentally ill people. It’s like a mental ward on the streets."

Homelessness among mentally ill is increasing

· The homeless population, especially homeless persons with serious mental illness, has increased steadily since the 1970s. This is seen in all major cities but also in smaller cities and towns. For example, in Roanoke, Virginia, the homeless population increased 363 percent between 1987 and 2007, and “70 percent were receiving mental health treatment or had in the past.” In Bangor, Maine, the shelter opened in 1987 with 10 beds. In 2007, the shelter had 33 beds “with a dozen paid staff members” to care for “people with a range of mental and physical health problems coupled with extreme poverty.”

· In 2006, Markowitz published data on 81 US cities, looking at correlations between the decreasing availability of psychiatric hospital beds and the increase in crime, arrest rates, and homelessness. As expected, he found direct correlations. This is consistent with past studies in Massachusetts and Ohio that reported that 27 and 36 percent of the discharges from state mental hospitals had become homeless within six months. It is also consistent with a study in New York that found that 38 percent of discharges from a state hospital had “no known address” six months later.

"Dumping" patients out of hospitals, saves mental health system money but increases overall cost to taxpayers by shifting care to more expensive jails and prisons.

.In 2001, a University of Pennsylvania study that examined 5,000 homeless people with mental illnesses in New York City found they cost taxpayers an average of $40,500 a year for their use of emergency rooms, psychiatric hospitals, shelters, and prisons.”

In many cities such as New York, homeless people with severe mental illnesses are now an accepted part of the urban landscape and make up a significant percentage of the homeless who ride subways all night, sleep on sidewalks, or hang out in the parks. These ill individuals drift into the train and bus stations, and even the airports.

Many other homeless people hide from the eyes of most citizens. They shuffle quietly through the streets by day, talking to their voices only when they think nobody is looking, and they live in shelters or abandoned buildings at night. Some shelters become known as havens for these ill wanderers and take on the appearance of a hospital psychiatric ward. Others who are psychiatrically ill live in the woods on the outskirts of cities, under bridges, and even in the tunnels that carry subway trains beneath cities.

Foreshadowing a grim future

There have been harbingers of an impending homeless crisis for individuals with untreated brain disorders since the early 1970s. Large numbers of ill people began forming psychiatric ghettos in cities such as Long Beach, New York, near Pilgrim State Hospital; San Jose, California, near Agnews State Hospital; and Tacoma, Washington, near Western State Hospital.

As large, often run-down, boarding homes filled with discharged psychiatric patients from the nearby hospitals, the intended policy of deinstitutionalization increasingly looked rather like transinstitutionalization – the exchange of one impersonal institution for another. At the same time, the availability of single-room occupancy hotels and other low-rent housing was declining precipitously in urban areas as redevelopment and gentrification shifted into high gear.

While this urban psychiatric ghettoization and decline in low-rent housing were taking place, it also was becoming apparent that many of the discharged patients were not receiving ongoing psychiatric treatment. Theoretically, they were to have received medication and rehabilitation services from the federally funded community mental health centers, but in most cases this did not happen.

As early as 1972, a study commissioned by the National Institute of Mental Health reported, "Relationships between community mental health centers and public mental hospitals serving the same catchment area exist only at a relatively minimal level between the majority of the two types of organizations."

By 1979, the Inspector General of the U.S. Department of Health, Education and Welfare was more blunt, saying, "The relationship between the CMHCs [community mental health centers] and public psychiatric hospital is difficult at best, adversarial at worst."

By the early 1980s, then, some unintended consequences of deinstitutionalization were becoming manifest. More and more very sick people were living on the streets and in public shelters.

A study of 187 patients discharged from Metropolitan State Hospital in Massachusetts reported that 27 percent had been homeless in the previous 6-month period. Substance abuse and failure to take medication were major predictors of homelessness. Among those patients who had been predominantly homeless, 63 percent had failed to take medication, whereas among patients who had remained in stable housing, only 18 percent had failed to take medication. Thus, increasing compliance with medication would significantly decrease homelessness among individuals with severe psychiatric disorders.

“In 2001, a University of Pennsylvania study that examined 5,000 homeless people with mental illnesses in New York City found they cost taxpayers an average of $40,500 a year for their use of emergency rooms, psychiatric hospitals, shelters, and prisons.”

Living in shelters or on the streets is likely to be difficult, even for a person whose brain is working normally. For those with schizophrenia or manic-depressive illness, this kind of life is often a living hell.

The majority of homeless individuals with untreated psychiatric illnesses regularly forage through garbage cans and dumpsters for their food.

A 1988 survey of 529 homeless people divided them into those who had been previously psychiatrically hospitalized and those who had not. The previously hospitalized individuals were three times more likely to obtain some of their food from garbage cans (28 percent versus nine percent) and much more likely to use garbage cans as their "primary food source (eight percent versus one percent).

In New York, 949 homeless men were interviewed regarding having been assaulted or injured. Twelve percent of the men were psychotic, and this group was significantly more likely than the nonpsychotic men to have been robbed, beaten, threatened with a weapon, or injured (concussion or limb fractures).

Padgett, D.K., and E.L. Struening Victimization and traumatic injuries among the homeless: Associations with alcohol, drug, and mental problems. American Journal of Orthopsychiatry 62:525–34 (1992).

In New York, seriously mentally ill individuals living in homeless shelters are said to be “easy marks for thieves and other criminals who live there. . . . Those who receive social security disability checks become targets for muggers. . . . There is a hierarchy among the shelter clients, and the visibly mentally ill are the lowest caste, untouchables among the outcasts.”

The New York Times (January 12, 1992).

Anecdotally, the stories bear out the studies. For instance, Albert Blanchard, a homeless man with a long history of schizophrenia and homelessness, was set on fire as he slept on a sidewalk in downtown Nashville. His sister noted that "Albert's paranoia would not allow him to stay in one place for long. He chose to live on the streets to keep the people the voices warned him of from finding him." As a result of the attack, Albert spent more than six months in the hospital and had eight separate surgeries.

A 1988 report on homeless women in San Francisco noted the women were being raped and sexually assaulted at an alarming rate, with some women being raped as many as 17 times. To protect themselves from attack, homeless women were known to wear 10 pairs of panty hose at once and bundle up in layers of clothing

Rape also exposes these women to deadly infection with the HIV virus that causes AIDS, especially since most of the men committing the rapes are drug addicts among whom HIV infection is common. No study has been done to date of the HIV infection rate among homeless women who have a severe mental illness. A 1993 study of HIV infection among psychiatrically ill men in a New York City shelter, however, found that 19 percent of them were HIV positive. Clinical AIDS will, therefore, become an increasing problem in the near future among the homeless psychiatrically ill.

Susser, E., E. Valencia, and S. Conover. Prevalence of HIV infection among psychiatric patients in New York City men’s shelter. American Journal of Public Health 83: 568-570 (1993).

Death

There is evidence that those who are homeless and suffering from a psychiatric illness have a markedly elevated death rate from a variety of causes. This is not surprising since the homeless in general have a three times higher risk of death than the general population and severely ill individuals have a 2.4 times higher risk of death during any year.

As part of a 1992 study in England, for example, investigators collected data for 18 months on 48 homeless people who also had a severe mental illness. They found that three people had died from physical causes (i.e., aortic aneurysm, heart attack, and suffocation during an epileptic fit), one had died in an accident, and three others had suddenly disappeared without taking any personal belongings with them. Depending on whether or not the missing participants were alive, the 18-month mortality rate was a minimum of eight percent and a maximum of 15 percent.

M. Marshall, & D. Gath, What Happens to Homeless Mentally Ill People? Follow up of Residents of Oxford Hostels for the Homeless, British MedicalJournal, 304, 79–80.

A 1990 study of homeless people published in Hospital and Community Psychiatry found that 43 percent of the cases showed the marked disorganization of mental illness and poor problem-solving skills (H.R. Lamb & D.M. Lamb). In an additional 30 percent, the subjects were not only disorganized but too paranoid to accept help. For example, two of the people had a place to live, but were too paranoid and fearful to stay there.

Freezing to death during bitter weather is all-too-common among the homeless in general, but especially among those with schizophrenia and manic-depressive illness. These deaths do not usually attract much attention, but on November 29, 1993, in Washington, DC, Yetta Adams was found frozen to death on a bench across the street from the headquarters of the Department of Housing and Urban Development (HUD). Ms. Adams suffered from schizophrenia and alcoholism and was living on the streets. When seeing a crowd outside his office, then-Secretary of HUD, Henry G. Cisneros, left his office to find out what had happened. He later wrote, "Yetta Adams’ death jarred me and all my colleagues at HUD, reminding us that our society is becoming an increasingly hostile environment for the homeless."

Cisneros, Henry G. The lonely death on my doorstep; Yetta Adams' story and the new war on homelessness, The Washington Post (December 5, 1993).

Murder is the most horrific cause of increased mortality among those homeless individuals with untreated psychiatric illnesses. While no formal study has been conducted, anecdotal evidence suggests that such deaths are not rare.

In Tennessee, two young men who “came downtown with plans to rough up the people who spend their nights sleeping on downtown streets,” killed Tara Cole by pushing her into the river as she slept. Cole, a 32-year-old woman who had been homeless for four years, had family and friends who wanted to help her, but she didn’t think she was ill and had stopped taking medication for bipolar disorder.

In 1993, three men and a woman, ages 19 to 22, beat a homeless man to death with baseball bats as part of a gang initiation. Randall Townsend, 42, had a severe mental illness and was living under a bridge. One assailant hit him in the face so hard that the bat broke. The other assailants then punched and kicked him and dropped a boulder on his face. Townsend never regained consciousness and died from head injuries.

Four charged in beating death of homeless man, The News Tribune (April 16, 2003).

In 1989, three young men savagely beat Van Mill, a 110-pound man with paranoid-schizophrenia who was living in a tent in Des Moines, IA, to death. After robbing and assaulting him, the Des Moines Register reported that "they threw him into an empty wading pool at the park and at least one of them jumped up and down on his chest, crushing his small frame, police said."

In a 1988 case in Washington, DC, Ella Starks, a psychiatrically ill woman who had been homeless for 10 years, was raped and according to a news story in the Washington Post was "stabbed repeatedly, and died of asphyxiation when an umbrella was forced down her throat."

Most homeless individuals with severe psychiatric disorders are not being treated. Most of them have anosognosia and are not aware that they are sick, but legally we protect their right to remain sick. As one news reporter noted: “It’s as if we suddenly decided to respect the ‘right’ of Alzheimer’s patients to wander wherever they please. Sounds ridiculous, but that’s basically the situation with so many of the people we call ‘homeless.’”

One Miami police officer commented: “Seeing another human being living like an animal in America, it just shouldn’t be like that. It gets frustrating not being able to do anything to help.”

Paper prepared by Dr. E. Fuller Torrey

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